Pre- Medical Appointment Questionnaire

Pet Name
Client Name
Date
Date Format: MM slash DD slash YYYY
Reason for visit:
1. What are the symptoms you are concerned about?
2. When did they start?
3. Is your pet in pain? What are they doing that tells you they hurt?
4. Has this happened before?
5. When did your pet last eat normally?
6. What food is your pet currently eating?
7. When did your pet last urinate?
8. When did your pet have it’s last normal BM?
9. Are they loose, watery, bloody?
10. Has your pet vomited? If yes, how often?
- Yes
- No
If yes, how often?
11. What medications if any is your pet currently on? Any supplements?
12. What flea/tick products do you use?
Client questions:
1. Have you or anyone in your household been exposed to Covid-19 within the past 10 days?
- Yes
- No
If so, when?
2. Have you or anyone in your household had any respiratory illness within the past 10 days?
3. What is the best phone number to reach you at?
Is there anything else you’d like us to be aware of regarding your pet or yourself?
Which type of appointment would you prefer?
- Curbside (wait in your vehicle while our team provides care)
- In Person Appointment (accompany your pet into the examination room)
- Outdoor Gazebo

East Lane Veterinary Hospital